Blindness and Eye Drop Webinar Transcript
Hi Everybody, and welcome to our first annual eye drop webinar.
We are so so excited to be doing this in collaboration with the Chicago lighthouse.
So we first want to give a huge thank you to everyone for tuning in, and then we also want to extend, you know, a great thank you to the Chicago lighthouse for putting this on with us. we had close to 700 registrants.
So. it’s been incredibly awesome planning at all, and thank you.
Thank you to everybody for being here, and also to the Chicago Lighthouse for planning it with us and for doing it with us.
For those of you who are joining us for the first time, We are accessible pharmacy services for the blind. We are home delivery, pharmacy, and we specialize in the needs of the blind, low vision and the deaf blind.
We are the only provider of its kind, and we are the largest, blind-owned, healthcare company in the country.
My name is Alexandra, and I am a senior director of business development and communications with accessible pharmacy. and once again, I cannot think, say enough.
Thank you for being here. throughout this webinar. Lisa will be here to supply us with ASL interpretation.
So thank you to Lisa, and also this webinar will have live closed captioning after the webinar is over.
In a couple of days. you know, over the next few days we’ll be sending out a follow up email that follow up email will have links to the video and audio recordings of the webinar resources from the webinar, and from our presenters, as well as a chance for you to respond with feedback.
We really highly encourage this, and we really appreciate it.
So please please do that before we get started. I just want to quickly run through some announcements.
We have so many exciting and fun things happening here at accessible pharmacy that I would just love to tell everybody about to start.
Our summer intern has officially started. and she’s been doing a wonderful job, so we just wanted to give her a huge round of a virtual applause.
Her name is, Beeshernah. She is a student at Stony Brook University, and we were introduced, to be sure enough, through vision services for the blind and visually impaired in New York.
So we are super thankful for visions and their college internship program. and we’re obviously very very thankful for Beeshernah and all the great work that she’s already doing with us.
We also wanted to let everybody know that We are partnering and collaborating with pace in Pennsylvania. this is Pennsylvania’s state prescription assistance program We’ll be kicking things off this summer. So if anybody is a resident or a healthcare provider in the State of Pennsylvania and has any questions, please contact us, we will also be expanding to other States prescription assistance
programs as well. Next month we are collaborating with the tech Al unit at Temple University to develop new packaging for individuals with limited mobility and spinal cord injuries.
We’ll be searching for individuals and volunteers to evaluate efficacy of this packaging and to test it out.
So we will circulate an email sometimes soon, sometime later, this summer.
To, you know. Ask for those volunteers. So this is an idea that came to us from one of our patients.
So we’re. researching it further with the team at Temple, and we’re eager to learn more some exciting dates that are coming up.
We are going to launch our accessible telehealth platform later this year.
Our goal is to match you know. providers with patients in an accessible and welcoming format. we’ll provide more information on this in the next few months, but we’re still super pumped about that our next webinar will be in the early fall regarding a comparison of glucometers.
And once we get a set a date set for that, we will be sure to let everybody know and I’m also very thrilled to ask everyone to save the date for December second.
We are hosting our first annual completely virtual blind health expo. and this one I do have a date for, as I said, it’s December second.
So make sure you save the date for that and it’s accessible pharmacies, blind health expo, and it will give healthcare providers and consumers a chance to meet and learn and talk all about solutions and services for blind and low vision patients. So December the second, it’s a Friday mark your calendars, and more information will be out soon.
My last exciting date, and my last announcement is actually for a week from today, and i’m honored to announce that Helen Keller services is awarding accessible pharmacy with an accessibility award next Wednesday. We are incredibly grateful for their recognition.
We hold Helen color services in such high esteem, and we thank them for everything that they do for the blind and deaf blind community everywhere. So thank you, Helen Kellerm Services. and we cannot say it enough. We are super super honored now to get to the webinar itself.
As I said before, we are doing this in collaboration with the Chicago lighthouse. We are so grateful for this Chicago lighthouse, and the wonderful things that they do every day for their with their
many, many patients and their programs, and the individuals who are working with us on the webinar today are absolute rock stars, and I’m honored to introduce them. Dr. Kelly Sharer is a low vision optometrist, and she is.
The Chicago lighthouse as director of clinical services, and Laura Hayes is the director of occupational therapy for the Chicago lighthouse. as well. They’re both phenomenal at their jobs and They have an extensive experience with patients from all backgrounds i’m absolutely thrilled that they’re doing this webinar with us.
So without further ado, please take it away Kelly and Laura.
Thank you for that warm welcome. Alexandra, with myself and Dr.
Sher are so excited today to partner with accessible pharmacy, and to bring to you this webinar on, I drop management for individuals with visual impairments.
The goal of the webinar today is to cover a range of topics.
We want to discuss things like how to organize your eye drops.
We want to talk about labeling. We will also talk about administration, and we will also talk about some troubleshooting, because there can be a lot of different kind of issues that can crop up when doing this and we want to try to hit this from all different angles. So, putting an eye drops obviously you’re all here today, listening, can be very very difficult and tricky, and some of the common issues that we often hear when putting an eye drops are things like touching the
tip of your eye drop bottle to your eye or your eyelid or even your eyelashes, so that can be a common issue that comes up a second issue that can happen would be just missing the drop entirely from your
eye. So you’re putting that to the drop in and then you don’t get it in, and as a result a lot of times you have to do it again, which can lead to wasting more drops than you you want and so missing can be another challenge. thirdly, administering more than one drop can be another area that can come up as well when people are putting in their address.
And so we’re gonna try to really touch on some tips and tricks to help reduce some of those issues that come up today to help make the whole process a little bit more easier for everyone.
And I will now pass it onto Dr. sheer She’s going to discuss some more general strategies for eye drop management.
Hi, everybody, and welcome. i’m gonna start with reviewing general tips that are gonna help you get your eye drops in and manage your eye drops a little bit better.
So tip number one is get familiar with your eye drops what you want to make sure you understand.
Is how you to take care of your eye drops and how to take them?
You can discuss these questions with the pharmacist or your provider who’s prescribing the eye drops.
You wanna ask questions like How many times a day do I need to take the medicine which I Does It go in?
Where should I keep it? Some drops can be stored in the refrigerator.
Some drops need to be stored in the refrigerator, sometimes keeping an eye drop in the refrigerator can be helpful, because the sensation of the coolness can help you to know whether or not the drop got into your eye. It also is helpful to know whether or not the medicine needs to be shaken or mixed before you take it.
And it’s also important to know what the side effects of the medicine could be if you don’t know that it’s related to the medicine.
You might not know to ask your doctor about it so that’s get familiar.
Tip number is keep it clean. it’s really important that you use good hygiene when taking eye drops to reduce the risk of getting an eye infection.
We first want to wash our hands before we take an eye drop and dry them thoroughly.
If you hands are wet it can make it hard to hold the bottle or your eyelid.
You want to take a tissue and keep tissues near you when you’re putting the eye drops in.
When you take the cap off, place it on its side on a clean tissue, and keep the rest of the tissues nearby, so that you can dab, if you need to.
The last thing that we want to do in keeping it clean is, make sure that you do not touch the tip of the I drop, or the I drop bottle to your eye or your hand or your eyelid this Can lead.
To Chris infection. it can lead to contamination of the medicine that should always stay clean and not test by anything.
So tip number one is keep it clean. Tip number 2 is get comfortable.
Positioning is very important for being successful with putting eye drops in the most common positions we recommend are sitting down or likeing down like on the sofa or a bed.
The next thing you need to do is really tilt your head back as far as you can, so that your chin is pointing towards the ceiling like Laura is doing here.
This naturally causes the eyes to open and so it’s easier to get your eye drops in, so that’s tip number 2 is get comfortable and tip number 3 is practice.
We’re gonna review multiple strategies for getting eye drops in, but not one size fits all It takes practice.
You might have to try a couple strategies to be successful.
All the bottles are also different. Some bottles require different amount of pressure.
To get one eye drop out, so you might want to practice these before you put it in your eye on your hand, with how hard you might need to squeeze it to get one eye drop out another recommendation.
We have when you’re trying to strategies is use an artificial tear.
These are over the counter eye drops that are inexpensive, and then you won’t be wasting your eye drops when you’re trying to figure out what strategy works the best So practice.
Tip number , tip number is take . If you have more than one eye medication that you need to put in at a certain time of day, you should be waiting min between the eye drops.
If you put eye drops in back to back it can cause the medicine to be less effective.
If you’re washing them out with a second drop so i’m gonna review the general tips are get familiar.
Know how to take your medicine. Keep it clean. Make sure everything stays clean and your hands are clean. Get comfortable.
Make sure you’re well positioned, and that your head is tilted back.
Practice. Not all strategies will work for everybody, so try different options and makesure you wait between your eye drops. Now Laura and I are going to discuss how to get the eye drop into your eye.
The first strategy i’m going to discuss and Laura is going to demonstrate we’re calling the classic.
This doesn’t require any equipment it’s just your hands. So what you’re gonna do is you’ll take your eye, drop bottle in your dominant hand, and grip it between your first fingers your
thumb, your index finger and your middle finger.
This is gonna give you a good grip and enough strength to squeeze the bottle.
You’re then you’re gonna tilt your chin back so it’s pointing towards the ceiling, and your head is tilted as far back as you can Use your ring your ring finger or your pinky finger to pull down in the lower part of the eyelid to make a little pocket.
Then you will squeeze the eye drop into your eye once you’ve gotten the eye.
Drop into your eye, close the eye, and press on the inner corner of your eyelid near your nose for about a minute.
This helps the eye drop to stay in the eye, and it helps to avoid it.
Getting into your bloodstream, where it can cause more side effects.
Remember that to have your tissues nearby in case you need to wipe at the end.
So that’s what we call the classic another option too, is if you’re having difficulty reaching your ring finger or your pinky finger to pull down that lid you can use your other hand next
we’re gonna review a strategy where you use a additional device to help get the I drop in.
So i’m gonna talk about our second strategy for eye drop installation.
We have called this the auto drop, and I will be verbally describing how to use this device, and Dr.
Shearer will be doing the demonstration over the video.
So the auto drop is a piece of equipment. it’s a plastic cup with a lid that is designed to help with positioning the eye drop bottle over your eye.
It also is a really helpful tool, because it can. It will prevent you from ever poking your eye.
When putting in the eye drop, as I had mentioned at the beginning.
Those are the the biggest challenges that we often hear is the alignment over the eye.
And then also you know, people making contact with their eye or their eyelid, and the eye drop can be very helpful in preventing those things.
The lid of the auto drop has a curved cut out, and that is where you will insert the neck or the thinnest part of an eye.
Drop bottle, and you will want to make sure that the bottle is pointing in towards the cup so we’re gonna show you some specifically again, how to do that with a few more steps.
So we’re going to first unclip the lid so unclip the lid, and then you’re going to take the I drop bottle and place it into that the neck of it into the lid as I mentioned before you will feel a cut out, and that will help direct you as to where to insert the bottle.
Once the bottle has been inserted into the lid, you will unscrew the cap from the bottle, and then you will need to snap it back into place, so the lid will just snap back into that main body of
the aid and you’ll actually hear a click to know that you’ve now secured the lid, and now you’ll be ready to use the dropper. so the next step would be you have to position yourself so as Dr.
Sharer said. positioning is extremely important so you want to Make sure that you’re leaning far back, or you’re laying down what you will do is you’ll take your free hand and you will pull down.
Your lower eyelid to create a pocket you will place the dropper over the eye, and if the lip of it should rest about above, just above your cheekbone, now that the it’s positioned over your eye, you need to look up potentially. You may see a pin prick hole of light when you do this.
If you do see that whole. Look up towards it if you don’t see it.
That’s okay, too. that’s not anything to worry about just make sure to look up.
Then you can squeeze the bottle to instill the drop once it’s been administered.
Take the dropper away, close your eye, and gently press on the inner part of your eyelid for min to ensure that the drop has been absorbed.
I want to just make a couple of other comments about the auto drop and just some some things to think about when considering this option.
It is designed to fit most bottles. however.
I have found occasionally depending on the size of the bottle that you’re fitting Sometimes they will not fit into that that click into that slot. So just something to think about if you’re considering this option is that there may be an occasion where you’re not able to fit a bottle into the auto drop.
However, I have found it to be successful with the majority of bottles.
Another thing just to keep in mind when using the auto drop is when you’re done with your drops, make sure that you take the bottle out and you stick you you secure the cap onto the bottle.
We don’t want to be leaving the bottles in the auto drop with the cap off, so it’s important to remove everything once you’re done, and you’ll have to kind of set it back up again when you have to do. your eye drops for the next time in the day.
These drops are available at the Chicago lighthouse.
As mentioned before, All of the acquaintance that we’re showing today will be linked.
So you’ll be able to locate where you could get these devices.
But this is something that we do carry at the www.Chicagolighthouse.org/store, So that was where you could locate the auto Drop. Our third tip or strategy. I should say for installation is using another type of device for your eye drops, and it’s called the gentle drop
So the gentle drop we’re we are showing an image of it on the screen.
I will also describe to everyone how to use it but the auto drop is actually a very new drop delivery aid on the market, and it’s so new that that’s why we don’t actually have it here to
demonstrate today. but it’s a silicon device, and it’s similar to the auto drop in that it does do some
It will position the bottle, but instead of stabilizing over your eye with a cup, it actually has a stabilization over the bridge of your nose, and so you would insert the bottle into the device.
And then you would place the aid over the bridge of your nose, and then you would.
The bottle would be positioned over your eye, and you could squeeze and instill the eye.
Drop that way. And so this was developed by ophthalmologists and they recently did a study on the effectiveness of it with glaucoma patients, and the results I don’t think it’s been fully published.
Yet, but the results were very promising that people found this to be very helpful for putting in the eye drops, and so we wanted to make sure that we mentioned this as another option.
When putting in your eye drops, you can locate this device at drop.
So now that we’ve gone through different strategies for administering your eye drops, we have the classic We have the auto drop and then we have the gentle drop. We wanted to shift gears to talking a little bit more about troubleshooting.
Because the reality is that when putting an eye drops there can actually be it’s multi-layered.
There can be actually lots of complicating issues going on beyond.
Necessarily just your vision. And so we really wanted to hit on some additional strategies that you might need to try to troubleshoot when putting in your eye drops.
So our first one is what to do. if your hands are shaky.
This comes up a lot for people. it’s not uncommon to have an unsteady hand, or have maybe a a mild tremor which then can make it very difficult when putting in your eye drops and so the the big tip that I can offer, for that is what you will need to do is brace, and so, when you’re putting in the eye, drop, you have to try to brace the hand that’s holding the bottle.
And so this is going to be a good trick for anyone who’s going the classic route.
So if you’re going with the classic route of instilling your eye drops, this might be helpful so a couple ways that you could try to brace would be to make a fist with both your hands and essentially stack them on
top of each other, and then put in the drop, and so, by stacking your hands.
Now your time has been stabilized to put in the eye.
Drop another way you could try. It would be to actually brace with the back of your hand, and place that on your forehead, so you’ll have to kind of turn your arm around a little bit, and then place kind of the side or back of your hand on your forehead, and then you can instill the drop from that position.
It can be a little bit tricky trying to maneuver this
But just try to keep in mind that principle of bracing.
Try to stabilize that hand while you’re putting in the eye.
Drop, my other suggestion would be. This is where the auto drop could also be very helpful.
Just the design of having that cup, it will naturally act as a brace for the bottle.
So if you have that in place, and then placed over your eye, it should hopefully help a bit.
If you do have a shaky hand. One other idea that I also have.
If those other tricks are not working for you is you could also consider getting like a one to light wrist weight, and actually put that weight on the hand.
That’s holding the eye drop bottle and and the reason for that is
We have found that for individuals who have, you know, mild tremors sometimes placing a little bit of light weight on the tremor, actually will stabilize your hand a bit more.
So you could consider trying a light wrist weight as well, to help with a shaky hand.
Another area for troubleshooting that we wanted to talk about is a related to difficulty with, you know, holding the bottle, and then also being able to see the bottle as Dr.
Sher had mentioned before. some bottles the drop might just fall right out when you do it, and then there’s some bottles.
You really have to squeeze, and it can be difficult.
So if there are any challenges related to arthritis or just dexterity, challenges, working with especially the glaucoma eye drops which are really small bottles, it can be challenging and so, what we suggest for this is You want to try to make the bottle bigger and more tactile.
So we have an example here of what I’ve done is where I’ve actually wrapped a small rubber band around the bottle, and what this can do is because it’s rubber it’s going to give a little bit more traction, when you’re holding the bottle so hopefully doesn’t slip out of your hands, so you could put the rubber band around, and that will help with your Grip when putting in the eye drop let you certainly could get clever with this. And just think about what types of things you might be able to put around the bottle.
The reason I do like the rubber band is that it also should help with still allowing you to squeeze the bottle to get the I drop out, so that would be one suggestion to help withholding the bottle the second suggestion is There is a device called the auto squeeze.
So we have another image of that device on the screen which I will describe.
It’s also a plastic device, it’s similar to the auto drop, and that it actually you can slide it and kind of click it into your eye. Drop bottle, and there are wings that will actually kind of protrude off the
side. And so the idea behind this is when you have those wings it will give you extra leverage when you’re holding the bottle as well as when you squeeze the wings together to put in the eye drop you won’t need as much pressure as you might need if you were to just use the bottle itself.
So the auto squeeze can be really helpful with helping you to hold the bottle, but also helping you to get the drop-in.
If you have a difficult bottle. Another nice thing about the auto squeeze, is it actually could be paired with the auto drop.
So if you wanted to use the auto drop to help with the positioning in the alignment, and then you wanted to attach also the auto squeeze to help with the squeezing and the holding of the bottle you can actually use both devices in Tandem. I’m now, going to pass it back over to Dr. Sharer. She’s going to talk about a few more troubleshooting areas and some resources.
Okay. So another thing that we often run into with eye drops is, the bottles are so small that the labeling is incredibly small.
So Even for people without vision loss. this can be really challenging.
This is a great opportunity for us to just review like who we’re partnering with today.
Accessible Pharmacy is really tackling this issue.
And so they have lots of different options for accessible labeling.
They have options for braille labeling. They have options for large print links, labeling, and they have options for audio labeling.
So I always recommend to my patients to contact accessible pharmacy. Talk about their level of vision loss, and talk about what issues they’re having with managing their medicines.
And they will provide you with some solutions to make it easier for you as well.
The other thing that you’ll notice with eye drops is they tend to come in different colored caps.
If you’re able to see color, this can be a useful strategy, Typically, medicines are categorized by the type of medication to each color.
So sometimes, if you do not remember the name of the medicine, knowing the color can help you to know which one you need to take.
This also can be helpful information to your provider.
If your doctor asks Well, what drop did you take this morning if you can’t remember the name sometimes.
The pink cap tells us enough another thing you’ll notice I’ve done on here is we sometimes will use different tactile labels to remember how often you need to take it this bottle I’ve wrapped small children’s hair ties around so I can feel it and know that I need to take it twice a day.
Another way to tactilely label is using adhesive stickers that we use frequently with vision loss called bump dots.
They’re elevated stickers and on this bottle we’ve put 2 again.
That would tell me. I need to take it twice a day.
I usually would recommend people stack them in a grid or vertical fashion, because if you stack them around the bottle it’s hard to count and know how many you have on there.
Sometimes there are smaller adhesive stickers called locator dots that for a really tiny bottle might work better.
They’re lower in profile, so you need to be able to feel well.
But they will fit on a very tiny bottle.
The other thing I wanted to discuss was difficulty.
Remembering whether or not you took the I drop eye drops are different than pills, because you can’t necessarily count.
You don’t say you can’t look in the bottle and say, well, there’s one less so a lot of times people forget.
Did I take it this morning, or did I take it before bed last night?
There’s a couple of different ways that you can improve your frequency or or your ability to Remember, if you take in the I drop, One is just using an alarm.
A lot of people use a smartphone or a smart speaker in their house, and you can name different alarms, so you could say, I have an alarm clock for pink cap at AM and PM and then when the alarm goes off, your phone would say, pink cap, and you’d say, Okay, I can need to take it.
Really helpful. The other suggestion I have just for tactile organization is if you have just some small boxes that you could put in order, and then, as you take the drop with each dose, you move it.
To the next box. Then, if later, in the day you can’t remember if you took it, you can go to see if it’s in the first or the second, or the third box, just move it along in a way that you would be able to identify the other common issue. We see is people running out of their medicine too fast, presumably because they’re putting too many drops in.
They’re missing frequently like we said a lot of the bottles administer too much at once.
So there is a solution that has been developed, called the Nano Dropper.
This is a cap replacement, or the tip replacement for the bottle.
So you take the cap of the bottle off, and the tip of the bottle is actually also removable on prescription.
Eye drops, and you replace the tip with this small, narrow distribute like tip that will distribute much smaller amount of medicine at once.
This is really helpful because it can take a drop and almost give you like a quarter of the amount, so that if it’s really spilling out when you’re trying to use it it’s turns it into a one drop
This This device is called the Nano dropper
We also recommend people practicing the how much pressure they need to apply to put the drop in, because we know that too much pressure.
Or for alignment is causing people to run out of drops like practice with those artificial tiers.
Get your strategy down, get your pressure down, and then you will be wasting less medicine.
The last thing we wanted to discuss was administering eye drops to other people.
Often as a visually impaired or blind parent, it can be really difficult to give eye drops to your kids.
So I have a couple of strategies for that. one is using a spray cap.
So spray caps are replacement tips for the eye.
Drop bottle similar to the Nano dropper. You remove the tip off of the bottle and you replace it with a spray bottle tip.
You can purchase these and put them straight onto your eye.
Drop bottle like this it’s important to check which side has the spray nozzle on it, so you don’t spray it in your own face, but you can administer this to somebody. and it’s very effective if getting the medicine into their eye as long as you’re close enough to their face.
It’s also very helpful in people who are uncomfortable with receiving the I drop like a child who is maybe a little bit difficult to stabilize.
Typically I recommend people just feel the person’s face so they know how close they are to them.
But as long as you’re within a hands with the medicine will get in just fine.
The other option for getting an I drop in to somebody who’s uncomfortable with eye drops.
Is tried to do it when they are asleep or relaxed.
I drops will get into the eye if you put them on in a closed eye.
Because tightly people feel it. They open the eye and it rolls right in It’s a relatively effective method.
If you’re having difficulty with the spray cap or with doing like a classic method on somebody else, similar strategies to what we talked about with putting an eye drop into your own eye, make sure that you use both hands to localize and to brace where you are to feel kind of where the bridge of the nose is, and then, if you have a an individual whose eyes are closed, you want to put it close to the bridge of the nose right in
the edge of the eyelid. Both of those ways are really safe and easy ways to get eye drops into pretty much anybody.
We use these strategies a lot in pediatrics outside of low vision.
To get eye drops in, and they work so that wraps up what we wanted to discuss with everybody.
We hope these strategies are helpful to you. We want to reiterate.
Eye drops are not easy. We know that it takes practice but we we know that some of these strategies have been effective for our patients, and we hope they’ll be helpful to you, too.
Thank you so much,
Thank you. Thank you. Thank you. Thank you. I cannot say it enough to both of you guys.
Thank you for doing this with us today. I just I just knew that the 2 of you would be the perfect individuals to put this webinar together, and I was right. you’re both so knowledgeable in this space.
I could listen to you. Talk about this stuff all day.
And you have such experience. and you know the ability to explain everything so beautifully.
So thank you for being here. and I hope for everybody else along with myself.
That it was helpful and yes, yes, that it it would just be helpful for everybody.
I also want to thank the Chicago Lighthouse for overall collaborating with us on this project.
And allowing us to have Laura and Kelly, or yes, Laura and Kelly with us.
Thank you for everybody for attending, and I hope that this was a helpful experience and a helpful webinar. Thank you to Lisa for helping us with the accessibility of the webinar Really, quickly.
As I mentioned earlier, I will be sending out a follow-up email in the next few days.
It will have a few things in it. First, this has been recorded, and a video and an audio link will be provided on that, email so that you can go back and have access to the whole thing real have access to all these helpful tips and techniques that Kelly and Laura have provided us other than that email.
Those recordings will be available on our website, http://www.AccessiblePharmacy.com and on our Youtube page.
Also in the email you’ll have access to resources from Kelly and Laura, and all of links to all of that information.
And then, when you get the follow up email, please go ahead and respond to it.
Let us know your feedback on the accessibility of the webinar, and how we can continue to make programs like this more accessible in the future.
And I would just like to say, before we leave that if you are not a patient of ours here at Accessible Pharmacy, we would love for you to join us.
We learn about how to support more patients by listening to our current ones.
So we would love for your feedback. and support as a patient.
That’s how we learn how to be more accessible and what other services we should be providing the easiest way to work with us is simply to just give us a call.
Our phone number is 215-799-9900
We would just like to thank you for attending our eye drop webinar
We were so happy to put it together with the Chicago lighthouse, with Kelly, with Laura, and with Lisa.